Coronial

83 results for intubation and general anaesthesia

NSWhospital2021-11-19

Inquest into the death of Emiliana OBUSAN

1y · Female·unrecognised oesophageal intubation

A 19-month-old girl died from unrecognised oesophageal intubation during anaesthesia for finger laceration repair. The anaesthetic team failed to recognise multiple clini…

anaesthesiaorthopaedic surgerydiagnosticcommunicationfentanyl
VIChospital2022-10-03

Finding into death of Travis Jack Blows

15y · Male·pneumonia in the setting of cerebral palsy and epilepsy

Travis Blows, a 15-year-old with cerebral palsy and difficult-to-control epilepsy, died from pneumonia after a prolonged PICU admission. He presented to ED mul…

neurologyintensive careclobazam
WAhospital2007-06-08

Inquest into the Death of Rasmussen

31y · Female·cerebral anoxia following attempted intubation pre-surgery in a woman with torti…

…orticollis, dysmorphia, short rigid neck), died on 17 June 2003 from cerebral anoxia following attempted intubation at Joondalup Health Campus. She was admitted for elective left inguinal hernia repair. Dr L., the anaest…

anaesthesiageneral surgerydiagnosticproceduralatracurium
VIChospital2023-06-06

Finding into death of Dianne Linford

63y · Female·Complications following sedation for percutaneous endoscopic gastrostomy (PEG) t…

Dianne Linford, a 63-year-old woman with profound disability from cerebral palsy and encephalitis, died from complications of sedation for PEG tube insertion. She had a congenital polymicrogyr…

anaesthesiagastroenterologyprocedural
WAhospital2013

Inquest into the Death of Kerr, William

86y · Male·Acute Myocardial Ischaemia in an Elderly Man with Valvular and Ischaemic Heart D…

An 86-year-old man with atrial fibrillation, ischaemic heart disease and hypertension underwent left inguinal hernia repair under general anaesthesia at a regional hospital. He exp…

anaesthesiageneral surgerycommunicationdiagnosticglyceryl trinitrate
NSWhospital2020-11-20

Inquest into the death of Melissa Stokes

49y · Female·Fatal Cardiac Arrhythmia

Melissa Stokes, 49, died from a fatal cardiac arrhythmia one day after successful abdominal hysterectomy and sling surgery. The coroner found the cause was not opioid-induced respiratory depression despite post-opera…

anaesthesiagynaecologycommunicationdelaytramadol
VIChospital2016-05-26

Finding into death of Delta Diawo Poke

42y · Female·Global cerebral ischaemia in a setting of anaesthesia

A 42-year-old woman died from global cerebral ischaemia following cardiac arrest during anaesthesia for a late-term termination of pregnancy. The anaesthetist, Dr McAllister, failed to obtain or ensure a…

anaesthesiaobstetricsdiagnosticmedicationpropofol
QLDhospital2005-08-24

Sabadina, Kathryn Marnie

28y · Female·Anaphylactic reaction to anaesthetic drug (suxamethonium), with underlying coron…

A 28-year-old woman died during routine dental extraction under general anaesthesia at a regional hospital. Despite competent initial airway management, she developed severe res…

anaesthesiadentistrydiagnosticproceduralpropofol
QLDhospital2006-03-13

Matschoss, Wayne Barry

60y · Male·bronchopneumonia as a result of or secondary to cerebral haemorrhage; contributi…

…year-old man with significant medical comorbidities including cardiac disease, epilepsy, chronic bronchitis and bronchiectasis, died in custody at Rockhampton Base Hospital from bronchopneumonia secondary to cerebral ha…

intensive carerespiratory medicine
SAhospital2020-10-12

Coroner's Finding: USHER Peter Michael

56y · Male·hypoxic ischaemic encephalopathy following insulin and benzodiazepine overdose

…t formally disclosed to healthcare providers, deliberately ingested temazepam tablets accumulated over time and insulin stolen from his mother on 10-11 November 2018. He was found unconscious in cardiac arrest with seve…

anaesthesiapsychiatrytemazepam
NSW2012-05-15

Grainger ,helen finding 1767 08 2012 05 31 14 40 06 300

29y · Female·Hypoxic Encephalopathy consequent upon Cardiorespiratory Arrest arising from eit…

Helen Grainger, 29, with polycystic kidney disease and asthma, underwent pregnancy termination at Lambton Road Day Surgery in April 2007. She developed anaphylaxi…

general practiceobstetricsproceduralsystemcephalosporin
WAhospital2003-08

Inquest into the Death of Richard Christopher Jankowski

39y · Male·Hypoxic brain injury due to respiratory obstruction following surgery for dental…

…rgery for a dental abscess with cellulitis. After initial treatment with antibiotics, he underwent incision and drainage at Royal Perth Hospital. He was extubated uneventfully and appeared to recover well in the recover…

anaesthesiageneral surgeryproceduralcommunicationpropofol
ACThospital2019-06-25

Inquest into the death of Jay Alan Paterson

43y · Male·hypoxic-ischaemic encephalopathy following polypharmacy overdose and iatrogenic …

Jay Alan Paterson, a 43-year-old man with chronic pain and opioid dependence, died from hypoxic-ischaemic encephalopathy following polypharmacy overdose and iatrogeni…

general practicepain medicinesystemproceduraloxycodone
WAhospital2013-11-11

Inquest into the Death of Kerr

86y · Male·Acute Myocardial Ischaemia in an Elderly Man with Valvular and Ischaemic Heart D…

… District Hospital. He had significant cardiac history including valvular disease, ischaemic heart disease, and atrial fibrillation. After his first hernia repair in June 2011, he experienced chest pain on multiple occa…

general surgeryanaesthesiacommunicationsystemglyceryl trinitrate
VIChospital2025-02-20

Finding into death of Mia Rose Iskander

0y · Female·Complications of ascending uterine infection (Klebsiella pneumoniae) in the sett…

Mia Rose Iskander died at 8 hours of age from ascending uterine infection (Klebsiella pneumoniae) with chorioamnionitis fol…

obstetricsneonatologydiagnosticdelayamoxicillin
VIChospital2020-09-29

Finding into death of Nicola Deleo

91y · Male·Complications following cardiac arrest in the setting of anaesthetic induction d…

A 91-year-old man with COPD, asthma, and previous cardiac arrest from suxamethonium died from complications following anaphylaxis to rocuronium duri…

anaesthesiageneral surgerycommunicationsystemrocuronium
VIChospitalNew2026-07-01

Finding into death of Baby H

0y · Male·traumatic head injury due to instrumental vaginal delivery of a term infant

…include: (1) Inadequate informed consent—Ms Brown was not warned of risks to the baby from forceps delivery and was not informed that the consultant obstetrician, not her GP, would perform the procedure; (2) Deficient t…

obstetricsgeneral practicecommunicationprocedural
NSWhospital2021-12-02

Inquest into the death of Joshua Szczudlo

33y · Male·Fatal cardiac arrhythmia, secondary to acute kidney injury

… apnoea) but surgery proceeded with appropriate anaesthetic management. Post-operative care occurred on a general orthopaedic ward rather than ICU. Key shortcomings included inconsistent supplemental oxygen delivery des…

orthopaedic surgeryanaesthesiasystemcommunicationmorphine
SAhospital2015-03-06

Coroner's Finding: SIMOS Theodoras Joannas

48y · Male·undetermined

A 48-year-old man with schizoaffective disorder, poorly controlled diabetes, sleep apnoea, obesity and cardiomegaly died unexpectedly at a rural hospital following acute psychotic agitation. He had absconded fr…

psychiatrygeneral practicesystemdelayhaloperidol
QLDhospital2026-03-31

Inquest into the death of Robyn Ann Beale

78y · Female·Hypoxic ischaemic encephalopathy as a result of obstruction of airway caused by …

…r taking oral pain medication (Endone) on the ward in the early morning hours. Critical delays in diagnosis and management followed: the overnight medical officer lacked endotracheal intubation skills and did not escala…

general surgeryanaesthesiadiagnosticcommunicationoxycodone

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